Microalbuminuria (microalbumin/creatinine ratio is usually sufficient)

EKG

CBC (rule out infections, or abnormalities that might render A1C less reliable)

Outlining the Treatment Approach

Based on the initial assessment, clear treatment goals should be set and shared with the person with diabetes. These goals should be defined as specific parameters. A list of goal parameters to consider might include:

The goals must be realistic. This might seem obvious, but it is often overlooked in the zeal of trying to achieve ideal results. Telling a person who is 50 pounds overweight that the weight-loss goal is 50 pounds might seem to him or her like an insurmountable task. However, a goal of losing 10 pounds might be more achievable, and probably would have a significant impact on key metabolic parameters. Similarly, while glucose and A1C goals should reflect Joslin or ADA guidelines, initial goals may be modified some, taking into consideration patient safety, abilities/willingness for self-care, and other medical conditions. Eventually, as the person makes some progress, the goals may be changed to reflect Joslin or ADA targets.

As these goals should be set in conjunction with the person with diabetes, it is also important to them in terms of specific tasks, educational goals, or behavioral changes (See Chapter 23). Such goals might include:

Lifestyle adjustments

Adoption of a new medical nutrition plan

Initiation of an activity (exercise) program (commensurate with cardiac and general medical status)

Changes in schedule or daily activities

Monitoring

Starting a program of self-monitoring of blood glucose, record-keeping, and/or adjustments of treatment parameters based on monitoring results

Identifying specific members of the healthcare team (educators, dietitians, exercise physiologists, etc.)

Seeking care from other specialists (ophthalmologists, podiatrists, vascular specialists, mental health professionals, cardiologists, etc.). Finally, it is important to determine a regular schedule of medical care and follow-up with any of the healthcare professionals needed for comprehensive diabetes care, and for monitoring risk factors and/or early signs of complications.

Medical Nutrition Therapy

For decades it has been said that "diet is the cornerstone of treatment for type 2 diabetes." Of course, the common understanding of the word "diet" is that it is something that people undertake in order to lose weight — something that, by its nature, is temporary "until the weight is lost!" People with type 2 diabetes tend to be overweight (having, in particular, abdominal obesity or the so-called apple-shaped body habitus) — so the impression that weight loss is needed is partially right. People with type 2 diabetes generally should lose weight, but the effort to change eating habits must not be temporary. In addition, by implication, this focus on "diet" suggests that weight loss is the crucial component in achieving control of type 2 diabetes. Being overweight — and overeating itself — both increase insulin resistance. However, as a result of the last few decades of experience treating type 2 diabetes, as well as recent advances and insights into effective treatment modalities, we now have a new perspective on the role of "diet" in the treatment of type 2 diabetes. First, we no longer refer to the eating plan as a "diet" because of the implication that it is just a temporary adjustment in eating to lose weight. What is needed for the treatment of type 2 diabetes is "medical nutrition therapy," which is a treatment that continues as long as the person has diabetes.

In addition, the primary focus is not weight loss. The goal is metabolic control, impacting glucose levels, lipid levels, and blood pressure. Weight loss may assist in reaching the desired goals or parameters. However, these parameters may be reached without significant weight loss, and even partial success with the recommended lifestyle changes may be beneficial in this era of expanded pharmaceutical treatment tools. The approach is not "all or nothing!"

Weight loss is still desired, recommended, and quite beneficial. In no way should it be implied that this is not an important goal and an integral part of the treatment program. However, it has long been recognized that many people have difficulty losing weight. There is tremendous anguish over the issue, causing much personal stress and interpersonal strife, particularly between spouses or other concerned family members or friends. The good news is that the pressure with regard to "diet" and weight loss is not as great as it used to be because of the new pharmacologic tools now available. Much research is underway to further understand the mechanisms leading to obesity — particularly abdominal obesity — and thus develop more effective treatments. There is now no excuse for waiting months and months for weight loss to occur.

Therefore, it is important to individualize the medical nutrition therapy to the needs of each person. Treatment goals should be those set by the ADA or Joslin for glucose control, lipid status, and blood pressure control. Weight loss goals need to be individualized and realistic. To tell someone who has been fifty pounds overweight for much of his or her life to lose fifty pounds is almost certain to meet with discouraging failure. Telling that same person to lose five to ten pounds may be more likely to meet with success, and it may only take the loss of that amount of weight to approach or even reach the desired metabolic goals.

Consultation with a dietitian or nutritionist can be quite effective in assisting people as they attempt to integrate a medical nutrition therapy program into their lives.

Physical Activity

For decades, it has also been said that, in addition to diet, exercise or physical activity is crucial to the control of type 2 diabetes. This statement, too, is correct. Exercise helps reduce blood glucose levels and insulin resistance.

However, like proper eating habits, exercise is often not undertaken by many people with type 2 diabetes as much as would be ideal. In addition, the word "exercise" is often frightening to people with type 2 diabetes, not just because they don’t like doing it, but because for those with sedentary lifestyles, "exercise" often implies something a svelte, young person in tight clothing does at a gym for one to two hours a day. Indeed, the potential for silent coronary artery disease should make such exercise frightening for the medical professional as well until the person with type 2 diabetes has had a cardiac evaluation!

The truth is that the term "exercise," as commonly used, may be ideal for those with type 2 diabetes, but is not the best initial approach. For people whose existence is primarily a sedentary one due to habit, age, or other medical conditions, just encouraging some moderate "activity" may be a sufficient increase in movement to have an impact on their metabolic status. Also, as with obesity, approaching activity gradually can often lead to greater success. Modest, periodic, stepwise increases in daily activity level can be more successful and medically safer than trying to push people into a more aggressive activity program than they initially can tolerate.

Physical activity has a number of benefits for people with type 2 diabetes. It:

improves glucose control

assists with weight-loss efforts, particularly with regard to abdominal obesity

However, as explained in greater detail in Chapter 6, before a person with type 2 diabetes initiates an exercise program, there needs to be careful prescreening and medical clearance:

review glucose control (although it might not be optimized until after the activity program has started) and make sure that the person can adjust his or her treatment to reduce the risk of hypoglycemia and/or treat the hypoglycemia if it occurs

cardiovascular evaluation (rule out occult coronary disease) and other measures of exercise tolerance and work capacity

ophthalmology evaluation (rule out the presence of active proliferative retinopathy which could bleed as a result of exercise)

foot examination to gauge the impact of peripheral vascular disease and neuropathy on exercise, and vice versa.

Indication for Antidiabetes Medications for Type 2 Diabetes

Antidiabetes medications are usually the first line therapy once lifestyle changes are no longer sufficient to achieve treatment goals for patients with type 2 diabetes. Various expert groups have developed guidelines, roadmaps, and recommendations for the advancement of therapies. For example, in a recent consensus statement, the ADA and European Diabetes Association recommend that antidiabetes pharmacotherapy with metformin should be initiated for people with type 2 diabetes as soon as the diagnosis is made and medical nutrition therapy and exercise started. Advancement of treatment to include additional antidiabetes therapies and/or insulin can be added when:

treatment goals are not met after 3 months of adhering to metformin treatment, medical nutrition therapy plan and exercise programs

symptomatic hyperglycemia is present

ketosis is present

there is imminent surgery

The American Association of Clinical Endocrinologists (AACE) has its own "roadmap" which provides a slightly different approach but the similar objective of trying to systematize an approach to reaching treatment goals for type 2 diabetes. Of course, Joslin also has a guideline for pharmacotherapy, reflected in this book and online at http://www.joslin.org/759_joslin_clinical_guidelines.asp.

The important point of all of these guidelines is not the differences in approach, but rather the recognition that we have many pharmacologic tools available to treat type 2 diabetes when it is deemed that lifestyle interventions are not sufficient to achieve treatment goals. With such an array to choose from, we each need to have a systematized approach in mind so that we can appropriately and in a timely manner initiate and advance therapy as needed. The good news is that because selection of medications that are now available to treat type 2 diabetes can specifically target the various pathophysiologic abnormalities, there is rarely a reason to delay treatment when goals are not met. Monotherapy, combination therapy, and even therapy with medications plus insulin are being used to successfully control glucose levels in many of these people. The various pharmacologic treatments for type 2 diabetes and how to use them are discussed in detail in Chapter 8, and designing insulin treatment programs is reviewed in Chapters 10 & 11.

Summary

The treatment of type 2 diabetes includes aggressive control of glucose, unless otherwise contraindicated. This starts with lifestyle changes, including medical nutrition therapy and an activity program. Self-blood glucose monitoring (SMBG) is an important component of treatment, not just to provide "test results," but also to gauge glucose patterns reflective of the underlying pathologic spectrum of abnormalities causing the diabetes, as well as to involve the person with diabetes effectively in his or her care.

As type 2 diabetes is so pathophysiologically tied to the metabolic syndrome and its array of cardiovascular risk factors, addressing these concerns is central to proper treatment for type 2 diabetes as well. Dyslipidemias, hypertension, vascular dysfunction, and hypercoagulability must be treated aggressively to maximize the potential for longevity and good health.

The outlook for those with type 2 diabetes is far better today than it was not too many years ago. With a renewed focus on lifestyle changes, new pharmacologic tools and a better understanding of risk factors and preventive strategies, there is a realistic hope of success in avoiding the many complications once thought to be inevitable. However, to do so requires a coordinated effort by healthcare professionals as well as the person with diabetes, his or her family, and the many others constituting the patient’s personal support system. While the new treatment tools do make the management of this condition much easier, the lifestyle changes and the challenges of avoiding or treating the complications still remain, and are usually the most difficult part of this condition.

Please Note: Reasonable measures have been taken to ensure the accuracy of the information presented herein. However, drug information may change at any time and without notice and all readers are cautioned to consult the manufacturer’s packaging inserts before prescribing medication. Joslin Diabetes Center cannot ensure the safety or efficacy of any product described in this book.

Professionals must use their own professional medical judgment, training and experience and should not rely solely on the information provided in this book to make recommendations to patients with regard to nutrition or exercise or to prescribe medications.

This book is not intended to encourage the treatment of illness, disease or any other medical problem by the layperson. Any application of the recommendations set forth in the following pages is at the reader’s discretion and sole risk. Laypersons are strongly advised to consult a physician or other healthcare professional before altering or undertaking any exercise or nutritional program or before taking any medication referred to in this book.